Provider Demographics
NPI:1891176160
Name:MICHAEL, ANNISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANNISSA
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7551 OSCEOLA POLK LINE ROAD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896
Mailing Address - Country:US
Mailing Address - Phone:863-852-1195
Mailing Address - Fax:
Practice Address - Street 1:7551 OSCEOLA POLK LINE ROAD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896
Practice Address - Country:US
Practice Address - Phone:863-852-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21211122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist